HomeMy WebLinkAboutMiscellaneous - 18 COLUMBIA ROAD 4/30/20181
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Date... D ....
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING'
,S$ACHUSEt
This certifies that .........�C.... .......... !9ezr- .��........ ��............
has permission to perform ..... 4.6e;z'��........................................................
wiring in the building of .......,........................................... c f
at f. �Co �/�� 12 , North Andover, Mass
Fee ... .�.............. Lic. No � 36,6 ... ......:....
..........
.��... �.......
ELECTRICAL INSPECTOR v
Check #
9294
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use
Permit No. `45 de
Occupancy and Fee Checked
Zev. 11/991 (leave hlankl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 52 CMR 12.00
(PLEASE PRINT ININK OR TYP ALL INFO IDN) Date; "
City or Town of 1h mw- To the pector of Wires:
By this application the undersigned gives notice,,,of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant _h5lrl
Telephone No.
Owner's Address
h this permit in conjunction wr a buil ung permit? Yes No ❑ (Check Appropriate Box)
Purpose of Buildmg/� ,4 �ty
Existing Service /Q® Amps olts Overhead [�
New Service Amps
Number of Feeders and Ampacity
Location ano Na of Propoo# E
eelelll!-
Volts Ovedtead ❑
Authorization No.
Undgrd ❑
Undgrd ❑
No. of Meters
No. of Meters
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Futures
No. of Cert-Susp. (Paddle) Fans
o. of . Tota
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No,., of Lighting Fixtures
Swimming Pool Above, ❑ - ❑
d. cmd.
o. o -Emergency Lighting
Battery Units .
- ._
No. of Receptacle Outkts 3
No. of OR Burners
FIRE ALARMS
No: of Zones _
... .... ..__ .... _.... . _...
No.'of.Switches t
. _ .. - ... -. .....
.....:. _--Burners
No. of Gas Burners
o. o electron an
Initiating Devices'
No. of Ranges - --
No. of Air Cond. Tons
No.`of Alerting Devices
No. of Waste Disposers
p
eat
Totals:
u er
'
ons
o. o -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of -Devices or Equivalent
No. of Water KW
Heaters
o. of No. Of
Sians Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommu ications rang:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing offi�XVAV
CHECK ONE: INSURANCE OND El OTHER El (Specify:) /�j-�
(Ex ratiDate)
Estimated Value'of Electrical Work: , 00 (When required by municipal policy.)
Work to Start: _Inspections to be requested in accordance-with`1v1EC Rule 10; and upon"completiori
I certify, under the pains. mrd penakies�of ury, that th-On formation. on.;his applteat on es true and�cotnplete: -
FIRIVI NAMES . s�A/QtgCE�/1/l�' LIC.;; NO.: 3PJ��d
__. _..r _...._... _
Licensee eSignature LIC. NO,/��//
(If applicable t y, = in the It �nj�mber ' .) Bus:` TeL 'No.:& Z 9 F�� Is,
Address. sAlta Tel No.:
OWNER'S INSURANCE WAIVER: I am aware t the icensee 4, 6,. not have the liability insurance coverage normally '
required by law.' By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent.
Owner/Agent PERMIT FEE. $
SignatureturaTelephone No.
s
s
i�
Date• '. /:? .. r 0
�'.��•:�� TOWN OF NORTH ANDOVER
PERMIT FOR.PLUMBINC
This certifies that `� h....L. t
has permission to perform ..,f'l0lJl2-. �........ .
plumbin in the /buildings of .. �� . G.... ��'��' ....... .
at ........... :........ North Andover, Mass.
Fee.3-7.. S-A . Lic. No.. . .......................... �.?.
PLUMBING INSPECTOR
Check #
9568
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
1
Owner 1A k
New ❑ Renovation C
Replacement
FW7T TV TW c
Date
Permit #
Amount
Plans Submitted Yes ❑ . No
(Pant in type) , P,, Checkone:Installing Company Name ^/ /�0&0� (f / ..iii( (�.o
Address u �� 0 ' 1470r LI Partner.
Business Telephone Q ❑ Firm/Co
Name of Licensed Plumber:
Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
1LJJ ❑
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature I
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) ' bove lication are true and "accurate to the
best of my knowledge and that all plumbing work and installations perform s for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumb' e 2 of the General Laws.
'Signature of Licensec
Title
Type of Plum ' icense
` �
City/ r e um �r Master r �//'
Journeyman
APPROVED (OFFICE USE ONLY • •� ■
k,
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Pr><nt LeQ>tbl
Name (Business/Organization/Individual).
Address: %� ///l fl ", , &,,1
City/State/Zip: /J --A u Phone #:Q
�7��
Type of project (required):
6. ❑ New construction
.7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submoit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_zP t'V r
Policy # or Self -ins. Lie. #:
/ Expiration Date: /(0
Job Site Address: O vii 6� �
City/State/Zip: A401d11_1__14tz
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerci u r t gins and penalties of perjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Aan employer? Chec k a appropriate
box:
:1.
a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees_ [No workers'
*..ny
comp. insurance required.]
applicant that checks box , ?must also fill out the
section below show:nm v
Type of project (required):
6. ❑ New construction
.7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submoit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_zP t'V r
Policy # or Self -ins. Lie. #:
/ Expiration Date: /(0
Job Site Address: O vii 6� �
City/State/Zip: A401d11_1__14tz
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerci u r t gins and penalties of perjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by city or town offciaL
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for\you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass..gov/dia
IV
Location
No. `7
Date X/- /"D,5
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
`
-Building Insped
TOWN OF NORTH ANDOVER
• BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT WA RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUR DING PERMIT NUMBER: 7 DATE ISSUED:
JAW/
SIGNATURE: -n-
Buildin C ioner `�r oEff4idings Date
SECTION 1- SITE INFORMATION
1.1 Propat Address:
A. -b
1.2 Assessors Map and Parcel Number:
09a . 0 �0 3
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Pio-posed Use
Lot Ates Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Rapired Provide ReqWred Provided
ReqWred Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Reord
Mike-
U-0—ONNOR -Q �AW ?....-
Name (Print) Address for Service
r !
`�
Signature Telephone
2.2 Owner of Record:
c-.�) C H�6�`�
Name Print Address for Service:
%
l • 9-r � C1--7�10 S
Sismakft Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
y
Not Applicable ❑
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Hovy)e_
T
Company Name
gCCS ( M
L
Registration umber
Add
J
u�
Expiration Date
Si afore Tel one
00
rn
X
Z
0.
v
rn
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the btu ing permit.
Signed affidavit Attached Yes ... ❑ No ....... ❑
SECTION 5 Description of Proposed Work check all
applicable)
New Construction ❑
xist$ttg hill ing ❑
��+"►
Repair(s)
, ❑
s') Alteration
+R,
' Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Descriptio of Proposed Work:
LAc� 5
o s
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed bypermit a licant
O OFFICIAL
91O0M
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, q - U & \ C�4 4 0c--Sd as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
-A ti C
Print N
Signature of er/A ent
NO. OF STORIES
Date
SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TR BERS 191,2
ND3 RD
SPAN
DIIv ENSIONS OF SILLS
DM ENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
THICKNESS
SIZE OF FOOTING
X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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D
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
11,S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
is
Fire Department Sign off:
Dumpster Permit
(Location of Facility)
i-�(44 aLt-Aw
Signature of Permit Applicant
J -As/
Date
AT-HOME
OME
.moiWea�"f�i? t'3t�45�7{y
fa
Installed
Siding and Windows
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: _ .126893
Irxptrafion 8/312006
+Type u13ilementCard
THE Home Depot At iiomd' Setvic
6TJNROEUN CHHOUY ,
3200 COBB GAL'LERiA PKIN`f #20
ALTANTA, GA 30339 Administrator
n—..dF..... 1A —A :....a,.n..a S... ODAA u........, c.....:,..... 1-- - u,... - n. --I ....a...a�...a __...__�....
e
- FROM : KIMBLY FAX NO. : 6033629679 Oct. 24 2005 07:32PM P4
Rom TMPRnvpu rxrr
C%JZN I MAC r
Branch Name: nate: Sold Furnished and Installed by:
(((---� 77-M At Home Servicer Inc.
d/b/a The Home Depot At -Rome Smvicea
Branch Number• _ _ Job #- ,�Q a 306; 345A Greenwood Stretn, Worcester, MA 01607
Toll Free Fedaal 00 75-M84W ME Lie 0 C 02439 RI Can657-5182; Fax: t 9
Lcr 16127
CT l km 563322: MA Horne lati" twit Contractor 1tts. M 126593
tllatallatian Address: R 61/ i n Ar 41- Ph 'o - ✓ A
State
Home Address:
(If dift'emt from Installation Address)
City State
E-mail Address (to receive updates and promotions from The Hama Depot):
Pr t I rm (/Wr1You (Purchaser"), the owners of the property lotted at the above installation addrr
contract with ome Depot U.S.A.. Inc. ("Horne Dapot") to fiunish, deliver and arrange for the installation of all m
described on the attached Spec Sheet #;
incorporated herein by reftmnce and made t
cannotHome { reserves the right to cancel this contract if, peon re -inspection of the job, $ome Depot deters
Worm i ohe contrations due in a structural problem with tete home or li mum work regujFed to coral
was not included in the contract.
Pluehasor agrees that, immediately upon Satisfactory completion of the w P=haser will execu R Completion
and pay any balance due. Purchaser also agrees to be jointly and wwverail obligated and liable her r.
weeny a ar Taus ageement and its attachments, including finenciog agtnernem, contain a co�nptete
patnes and canna he amended or modified unless in writing in a Somata agreement signed by both par,
Zip
NOTICE TO PURCHASER
Do not alga thb cootrad before you read it. You are ondtkd to A avmpletety 0119"o copy or the eentraet at the time you a
b fe protect your rights. no not siRo auy Completion Certlncate at, agreemeat stating that you are tatis� with the Batt
before the project to The w te. coraLaw etigg at home r air evrttraetors ftot7 re�uadttg or mccpting a Completion Canine
by Ute owner prior to the acioat camplenoa o[ the rror to be performed ander PontraM-
Yon L7.411.1
tancel this karrsaatioa at nay time prior to mldnii�t of the third buttlaaas day ager the dart at this coatrrtcL $ce
CaaocBanoo tot an ex ptauatkon of this right. Then Vt a tamrvkr charge equal to 25% of the eatttract amount 1f t
cancelled by pyrtLaycr AFTER the third husivess day.
BY MY/OUR SIGNATURE BEI.OW,1/WE AGREE TO BE BOUND BY THE TERMS OF Ty1S CONTRACT. ME ACIWOwLEDGE
RECEIPT Olt A COPY OF THIS CONTRACT AND TWO COMIPL&TED COPIES OF THE NOTICE OF CANCELIA 1TON.
!' CA DIT HIS SIGNA?�JRl BELOW, 1/wE UNDERSTAND THAT THE �� IS SUBJECT TO REVtiiw OF MY/OUR
1 CREDIT HISTORY AND VWE AUTHORIZE HOW DEPOT AUTHORlZ» WNT itEN TOR, TO JE CT T AND REVIFW My/OUR
fff EM
CREDtr RECORD W>TH AN INDEPENDENT CREDIT REPO
AGENCY AND
j INCURRED FROM INADVF SS O=ORRTMO.NdT ENC TRIS REIZ ASCITHEM ' 7�ROM ALL
ANY BB [Lrry
SPACES.
ANK
SUBMITTED BY: Dale:jo
e6ACCEFrM BY:
��Date• d
Aothoowaer Date:
N[YrrCp "WrIONAL YERMF, CONDI ONS AM WARRANr=AU ST.A'tCn ON THE RnVaUR a7pg ANa ARF PARYOr TMs oowMCr
G2/-05 G White- 7Nambpits YNIe.-Qaiaraer Piak-fiw-cawftw
-8C
4—
DEPOSIT PAYhMNNTT O ONS
(ShbjK1 taftme verjWA6oa &,V.r o ! rgtptavala
7n
CONT
i' � t orlJ3DP-).gorv;oe oaryReder
vc 7WP
*LESS DEPOrj� S_ �7
2. Credit Card- an4/or paymant optic arae 0. Bela
BAIANCE DU /
Vim Msetafraw WaWr titan F"M
ON CONPLF;TION $ )10
The Home Dapot Hoa, improv at Loan The home bepd
01111n 2,1;% or Contract Amann, due upon "Mmiton
Awihbte Credo: s (SIT, tr Imcc On
tagkACt.
AoW:._�
Exp. Date:_
�Iadicate
KAMM as it Appea=a as tool`
Payment Met o o>Mh d r
—
BAI.ANCE DUE ON COMPLETION:
'BY myrour Alpau. bal.., Uwe roe Allow Hone mpot to ab
=eibtacad emu Gaol for me depo iadt
CatdhddeAa siss'dute Tie
Pluehasor agrees that, immediately upon Satisfactory completion of the w P=haser will execu R Completion
and pay any balance due. Purchaser also agrees to be jointly and wwverail obligated and liable her r.
weeny a ar Taus ageement and its attachments, including finenciog agtnernem, contain a co�nptete
patnes and canna he amended or modified unless in writing in a Somata agreement signed by both par,
Zip
NOTICE TO PURCHASER
Do not alga thb cootrad before you read it. You are ondtkd to A avmpletety 0119"o copy or the eentraet at the time you a
b fe protect your rights. no not siRo auy Completion Certlncate at, agreemeat stating that you are tatis� with the Batt
before the project to The w te. coraLaw etigg at home r air evrttraetors ftot7 re�uadttg or mccpting a Completion Canine
by Ute owner prior to the acioat camplenoa o[ the rror to be performed ander PontraM-
Yon L7.411.1
tancel this karrsaatioa at nay time prior to mldnii�t of the third buttlaaas day ager the dart at this coatrrtcL $ce
CaaocBanoo tot an ex ptauatkon of this right. Then Vt a tamrvkr charge equal to 25% of the eatttract amount 1f t
cancelled by pyrtLaycr AFTER the third husivess day.
BY MY/OUR SIGNATURE BEI.OW,1/WE AGREE TO BE BOUND BY THE TERMS OF Ty1S CONTRACT. ME ACIWOwLEDGE
RECEIPT Olt A COPY OF THIS CONTRACT AND TWO COMIPL&TED COPIES OF THE NOTICE OF CANCELIA 1TON.
!' CA DIT HIS SIGNA?�JRl BELOW, 1/wE UNDERSTAND THAT THE �� IS SUBJECT TO REVtiiw OF MY/OUR
1 CREDIT HISTORY AND VWE AUTHORIZE HOW DEPOT AUTHORlZ» WNT itEN TOR, TO JE CT T AND REVIFW My/OUR
fff EM
CREDtr RECORD W>TH AN INDEPENDENT CREDIT REPO
AGENCY AND
j INCURRED FROM INADVF SS O=ORRTMO.NdT ENC TRIS REIZ ASCITHEM ' 7�ROM ALL
ANY BB [Lrry
SPACES.
ANK
SUBMITTED BY: Dale:jo
e6ACCEFrM BY:
��Date• d
Aothoowaer Date:
N[YrrCp "WrIONAL YERMF, CONDI ONS AM WARRANr=AU ST.A'tCn ON THE RnVaUR a7pg ANa ARF PARYOr TMs oowMCr
G2/-05 G White- 7Nambpits YNIe.-Qaiaraer Piak-fiw-cawftw
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FROM : KIMBLY
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FAX NO. : 6033629679 Oct. 24 2005 07:31PM P1
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CLAIMS DEPT.
May 24, 2005
commerce Insurance
The Commerce Insurance Comuany
Citation Insurance Company
Members of The Commerce Group, Inc.
11 Gore Road, Webster, Massachusetts 01570 (508) 949-1500
www.Commerceinsurance.com
BUILDING COMMISSIONER or
INSPECTOR OF BUILDINGS
TOWN/CITY HALL
N ANDOVER MA 01845
RE: Our Insured:
Property Address:
Policy#:
Date of Loss:
File#:
MICKkEL F OCONNOR
18 COLUMBIA RD
PP6061
05/22/2005
CHR521-VRY890
Board of Health or
Board of Selectmen
Town/City Hall
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
DEANNA L DAVIS
Claim Adjuster
Telephone: (508)949-5038
Toll Free: 1-800-221-1605, Ext: 5038
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
May 24, 2005
Cc111mCre Ccmpaniles .... COME GROW WITH us
CIC 254 (Rev. 4/95) MAIL
560